MARCH MANIC | Lisa Jacobs
There were 10 pairs of colorful skis standing upright outside my door when I left for my tenth 14-hour overnight shift in two weeks.
“I’ve finally lost it!” I announced to no one. “My psychotic break. It’s actually happening.”
The nearest slope was half a day away and I was the only skier in my building. Either the skis magically appeared during my nap or I was hallucinating.
One terrifying lesson of psychiatry is how fast your brain can turn against you. You’ve been fine your whole life? Doesn’t matter. The sanity grounding you to reality can turn to quicksand at any moment. It’s like we’re all driving around in glass cars. The view’s great, but one crash and it can shatter to a million pieces. Reality is frighteningly fragile.
I stood paralyzed like a deer in headlights. Should I report to work if I’m losing my mind? Would the patients notice? My shift was starting in 15 minutes.
I rubbed my eyes. The skis were still there. I reached out to touch one to see if it was real, hand trembling, and they tipped over like dominoes, the last few pairs flying down the stairs with a crash.
“These skis are real,” I told my neighbor who’d sprinted the stairs to see if I was okay.
“Damn girl, what you been smoking? No shit, they’re real,” he said. “Sorry to take your hallway. Some guy owed us and this is all he had. Want a pair? You fuck with the snow?”
I’d been trying to save up my measly salary for skis for years, but that’s how I got my first pair. Maybe it would be an okay night after all.
Within 30 seconds of entering the psych ER, I knew I was wrong. Three different phone lines were ringing and 15 patients were on the board, five unseen. Everyone was running around in chaos.
“It’s March madness,” Chris, the resident signing out to me, said. He looked pale and tired and was devouring a stale turkey sandwich from the patient fridge, an act of desperation. “It’s been like this all day. I’m losing my fucking mind.”
He wasn’t talking about basketball. March is the worst in psychiatry. One theory is that people who got depressed in the winter finally get the energy to try to kill themselves when the daylight shifts, but it’s also prime-time for psychosis. Like most things in psychiatry, we know the pattern and how to treat the symptoms, but have no clue why things happen the way they do.
“It’s okay,” I said. “I thought I had a psychotic break an hour ago.”
“I swear I heard voices last night. I actually turned and there was no one there. We’re all losing it,” Chris said nonchalantly, and then he was gone.
I evaluated 20 patients that night. It was like the I Love Lucy episode in the chocolate factory – one gone, two more pile up.
There was a 60-year-old woman with chronic pain who’d just gotten laid off from her secretarial job of 40 years. The police pulled her off a bridge and brought her in against her will. Admitted.
There was a 46-year-old homeless guy, who wrote “suicidal, homicidal, schizophrenic, bipolar” on the intake form, but told me he “really just came to say what’s up” because he hadn’t been by the ER in awhile. Discharged.
There was a 25-year-old guy who was found walking by the train tracks covered in poop, carrying a bunch of rocks, and mumbling. Admitted.
There was a 30-year-old woman who was hearing voices and had been pulled out of the freezing river by police naked, trying to “swim home” to Kansas. Admitted.
The patients were so sick, the staff didn’t give me any pushback as I overcrowded our ER with patients awaiting placement.
If you have a stroke or heart attack, you get admitted to the hospital and we figure out insurance and money later, but if you come in suicidal or psychotic, you sit in the ER, maybe for days, until a hospital reviews your file and agrees to take you. Your insurance must agree to pay first or a hospital has to agree to charity care. Psych units can reject patients for any reason, most often saying, “nursing is uncomfortable.”
By 5AM, I was beyond any point of exhaustion I had known. I retreated to the call room, a windowless converted office that was 85 degrees with a broken thermostat. A mountain of dirty sheets in the corner stank. There was a rumor of mice. I didn’t care. I passed out face-down with my shoes on and jumped through the roof when the phone rang like a foghorn 15 minutes later.
“Sorry, doc, got another,” the crisis counselor said. I groaned and walked to the office, where he handed me a stack of paperwork and continued, “Easy one. Got out of inpatient today. Has meds, has follow-up, not homeless, not suicidal. Slam-dunk discharge. Just see her quick.”
She had brought pill bottles containing lithium and antipsychotic tablets for mood stabilization, filled that morning when she got out of the psych unit.
I stumbled out into the loud and rowdy waiting room and saw her dancing in the corner.
“Come with me,” I said, and five other patients pointed to themselves hopefully while she kept dancing. I went closer and pointed to her, “You, come with me.”
Her name was Aviva but she told me to call her Abbi or Ilana because “those bitches be the bomb.”
“Broad City?” I asked, rubbing my eyes. I liked that TV show, too.
Her eyes brightened and she stood up and started dancing around the interview room. She wasn’t at all threatening, so I just let it go. She was humming the show’s theme song, saying, “Yaas queen, you’re mad Jewey like them and me. Give those ladies a shout! That’s what I’m talking about! Abbi’s from the Main Line like me. We both do comedy.”
“You do comedy?” I asked.
She continued, “So many fish in the sea,” and “Phish is the band for me” and “those phishing schemes ain’t got integrity.”
“Nice rhymes,” I said.
She was obviously manic. She sounded like a Dr. Seuss book with her “clang,” and had a “flight of ideas,” bouncing from one subject to the next. It was clear she hadn’t slept all night and unlike me, didn’t feel she needed the sleep.
“Where were you tonight?” I asked, yawning.
“Had to party, had to work, had to twerk,” she said, as she started twerking. Her moves were good. She made me laugh. I liked her immediately.
“Drugs?” I asked. I was having trouble formulating full sentences.
“A beer for me, a beer for you, but don’t do drugs, don’t be a foo’,” she said. Long story short, after a prolonged and labored exchange, she said she drank two beers but never did drugs.
She just kept talking. Talking and talking and talking. Her voice was so loud and I had the worst headache. Please stop talking, I thought. Her mouth was on a motor. I could barely get a word in edgewise. My head was pounding and it seemed like the fluorescent lights overhead had somehow gotten brighter than ever before.
“How’d you get here?” I asked.
“Security didn’t want to see my titties. They said insanity, but it don’t have that gravity,” she said.
It took me awhile to figure out that she was talking about her hospitalization a few days ago for her first manic episode. I was scanning the medical records she brought with her as she danced and rhymed.
She was a college freshman who was depressed in high school but never manic before now. She was diagnosed with bipolar disorder after spending $10,000 in a casino, ripping her shirt off, and standing on the craps table asking who wanted to “have a go.” Luckily the only one to respond was a security officer, who had the sense to call an ambulance rather than the police.
The papers said she quickly stabilized and was never dangerous or suicidal. No mention of her family was made, which would generally concern me for a 19-year-old, but I was so tired it didn’t register. I was thrilled that she was on good medications and had a psychiatrist appointment in two days. There didn’t seem to be any imminent danger or reason to try to hospitalize her.
“Can I call your parents?” I asked.
“Mom’s in Asia on a business trip and dad’s a dick,” she said. “And a prick. He don’t care that I’m sick.”
She denied suicidal or homicidal thoughts and didn’t seem psychotic. Still, manic patients can ruin their lives from sheer impulsivity – in a day, you can write a nasty email to a boss or professor, blow through your bank account, and cheat on your partner.
Was she taking risks? Spending money? Having promiscuous sex? Taking on odd projects that would get her in trouble? She said no, so it seemed hard to justify an emergency worthy of breaking HIPAA privacy laws to call her parents against her will. Usually, I would have pushed harder, but all I could think about was sleep.
“Why did you come here, again?” I asked 30 minutes into the interview, confused, but I didn’t even wait for the answer before asking, “Want to go home?”
She agreed, saying, “Doesn’t matter anymore. It’s all a bore. Sure, sure, sure.”
I was confused. My thinking was foggy. I went to the staff room, rubbing my eyes and asked the crisis counselor, “Why is she here, again?”
“Who knows,” he said. “Probably bored. Send her home?”
I nodded, but was distracted by my clipboard. There was a post-it note in Spanish. How odd, I thought. I don’t even speak Spanish. I stood there for a moment, marveling at my newfound linguistic abilities.
“Whatchya doing, doc?” the crisis counselor asked.
“Do you know what this means?” I asked, handing him the note. I was so tired that I basically felt drunk.
“It’s the list of Spanish TV shows I gave you when you said you liked Narcos,” he said. “Go get some rest, doc.”
I went back to the call room and fell into bed for somewhere between two and 20 minutes when the phone rang again.
“Avivia’s dad on the line,” the crisis counselor said. “Sounds upset. Patching him through.”
“I’m looking for my daughter,” he said. “Can you help me?”
I explained that I couldn’t confirm or deny if I had seen her since I can’t release information without a patient’s consent, but I could take information.
“She’s been missing for four days,” he continued. “The college doesn’t know where she is, her friends don’t know, and her phone is off.”
Clearly, no one called him from the hospital. He went on, sounding panicked, “She left me a voicemail a few hours ago saying ‘goodbye and fuck you.’ She said she’s going to kill herself by walking in front of a train tonight. I called the police and five hospitals, but no one will help me. I don’t know what to do.”
My heart sank. Maybe she just wanted attention or was being provocative, I hoped. Maybe she said things like this to her dad because she hated him and wanted to worry him. I asked, “Has she said things like that before?”
“Never,” he said. I could hear him crying on the other end of the line.
Fuck, I thought. I had made a technically correct decision that was totally wrong. I felt like anything that befell her would be my fault. She had obvious risk factors for suicide: bipolar disorder, recent discharge from an inpatient unit, and alcohol in her bloodstream. I should have dug deeper. I should have pushed her harder for information. I should have called her parents without her permission.
I put him on hold and sprinted down the hall, hoping to intercept her before she was discharged.
“Where is she?” I asked security, out of breath.
“Gone,” they said. “Just left. You discharged her, didn’t you?”
“I gotta get her,” I said. “Unlock the door.”
She wasn’t my patient anymore. If I started an involuntary petition and called it into the police, it might take them hours or days to find her and bring her back to the ER. She could be missing or dead by then.
“You gonna chase a patient in the street, doc? We don’t do that,” the security officer said. “They come to us.”
“Let me out,” I said.
As soon as I reached the pavement, I saw her in the distance, walking towards the rising sun, vaguely in the direction of the train tracks. I ran. In half a block, I tripped on my scrub pants, which were way too long, and fell. My pants were ripped and my palms were bleeding by the time I caught up to her, out of breath.
“Wait!” I shouted. “I made a mistake. I shouldn’t have let you leave.”
She shrugged, and kept walking. I followed her.
“I haven’t slept more than three hours straight in a week. You know what that’s like, right? I’m not thinking straight. I didn’t hear what you were trying to tell me. Probably, no one has,” I continued.
Her face looked blank, unmoved, and she kept walking. I stood still and did something you’re never supposed to do in front of patients: I cried. Not a few tears, but full, loud, uncontrollable sobbing she could easily hear down the block. It was sudden and unexpected, like a floodgate opening. I slumped against a brick wall, thinking I had just signed her death warrant and there was nothing I could do.
She wandered back to me and asked, “You okay?”
“Give me another chance!” I said, trying to wipe away the tears and catch my breath. “Please, please, give me another chance. I’ll never forgive myself if something happens to you tonight.”
If anyone saw us, they would definitely have thought I was the patient, crying and disheveled, collapsed against a brick wall while she stood above me, well dressed and now calm.
“It’s okay, lady psychiatrist queen,” she said, “I’ll go with you.” She reached out her hand to help me up off the ground and led me back to the ER.
Lisa Jacobs, MD, MBA, is a fellow in Child & Adolescent Psychiatry at Stanford University, where she serves as an assistant director for The Pegasus Physician Writers. She was the 2019 recipient of the Irvin David Yalom, MD Literary Award for an excerpt from her first book, which she is currently writing. Dr. Jacobs did her undergraduate studies at Cornell University, earned an MBA from the University of Rochester, and completed medical school at Brown University. As a resident physician in psychiatry at The University of Pennsylvania, she was the founding editor of The Penndulum magazine. Dr. Jacobs has a private practice in adolescent and adult psychiatry in Palo Alto, California.