Our psychiatric unit was unusual in that we didn’t have separate facilities for the very young, the very old or the very aggressive. It made for an interesting mix of people. For some patients, this was all they knew and nothing surprised them. For others, particularly those involved in the world inside their head, there wasn’t much that could shock them. But there were some people whom you or I might consider normal – rational people who suddenly found themselves in the middle of this madhouse – for whom time in our ward was certainly an eye opening experience.
Catherine was 18 when she was brought to the psychiatric unit. She was polite and clever – due to graduate from high school in a few months’ time. She had great grades, and had been accepted into university. She had a bright future in front of her. Until she did something that could potentially affect the rest of her life. She attempted to overdose on paracetamol.
Catherine needed help, and wanted people to know it. She thought by overdosing on a legal drug it would make people take her seriously.
Paracetamol is one of the safest yet also the most dangerous drugs in the world. Most people think it harmless, and why wouldn’t they? It’s often the first line of drugs given to children, even infants. It is safe, completely safe, in the right dosage.
What many people don’t know is that if too much is taken, paracetamol destroys the liver. Even a moderate overdose – as little as a dozen tablets – can cause permanent damage. Higher doses can mean death, or at a minimum, the need for a new liver.
Fortunately for Catherine her liver had been saved. As soon as she had taken her overdose, she’d called an ambulance. When she’d been brought into the emergency room, the staff commenced an infusion of a drug which acts as an antidote to paracetamol.
I’d been working in the psychiatric unit for over a year when I met Catherine, and I was still considered inexperienced. I was rarely given female patients – instead, I was generally allocated younger males, sometimes aggressive. But today, as there was a shortage of young troubled male teenagers for me to look after, I was assigned Catherine.
Even though Catherine was technically an adult, she was still a school kid, and I knew it would be best to keep a close eye on her until she got used to the place.
I found Catherine walking down the corridor, clinging to the wall, unable to stop herself staring at everyone who passed. ‘Why do they look like that?’ she whispered to me as a particularly interesting specimen walked by.
‘What do you mean?’ I replied.
‘You know what I mean, look at him,’ she said.
The case in question was Jacob, a 35-year-old schizophrenic who’d been diagnosed at the age of 16. I knew Jacob well and I knew what Catherine was talking about, but I wanted to hear what she had to say – not out of spite, but so that she could get the most of her experience in a psychiatric unit.
‘Well . . .’ She paused, thinking carefully about what she should say. ‘He just looks insane. And what is he smiling at? It gives me the creeps.’
When Jacob’s schizophrenia was in a good mood, the voices in his head were nice, sometimes even entertaining (although what you or I might find entertaining may not be exactly the same as what Jacob found entertaining), perhaps he was smiling at that. Of course, there was every possibility he was laughing at the cursing and other foul language directed at us, originating from the monster standing beside me.
Catherine and I made our way to the dining hall. I found her a table near the door, and left her alone while I rounded up the stragglers for dinner. I had just herded the last of the patients into the dining hall when I noticed Jeffrey sitting, staring at his food, mumbling under his breath.
Jeffrey was 20 years old, and like Jacob he suffered from schizophrenia. I’d slowly got to know Jeffrey over the few weeks since he had been admitted, and it had taken all that time before he began to acknowledge me. Well, acknowledge me probably isn’t quite right, it took him that much time to begin to trust me. Every day when I began work, I had to show him my staff ID card to prove that I was actually a nurse.
‘Everything okay?’ I asked. Jeffrey looked up from his plate, and mumbled an incoherent reply.
‘What was that?’
‘I’m not in the mood. Leave me alone.’
I left Jeffrey in peace, but stayed in the doorway observing the diners, as well as glancing regularly in his direction.
Jeffrey had done what some people with schizophrenia commonly do. He had stopped taking his medications. Sometimes the reason for this is that the medications they take make a huge difference. They can completely stop the voices or visions, and allow patients to lead a completely normal life. What then happens is the patient might start to think they are cured. Maybe they forget to take their medications regularly, maybe they’re sick of the side effects of their prescription, or maybe they start drinking a bit of alcohol, or have a puff of a joint. In some cases all it takes is one smoke or one night out on the booze to hurl them back into an acutely schizophrenic state.
Jeffrey was studying architecture at university. He’d not had an admission to hospital in two years, mainly because he took his medications. He had then begun to occasionally forget his medications, before he stopped altogether.
Unfortunately, he didn’t recognise that he was falling into a crisis. It was only after his mother got concerned that he wasn’t answering his phone for several days that she paid him a visit and found him locked in his room, terrified of the world outside.
Paranoia is a common presentation. It can begin with something simple, like the voices start telling them that the medicine is really poisoned, but the delusions can come in an endless variety of ways. Maybe the television starts broadcasting straight into their heads. Whether it be a subtle, or sudden and violent, relapse, it is a very serious and frightening state to be in, both for the patient and the family or friends around them.
When I next glanced at Jeffrey, I noticed him staring intently at Mr Pike. Mr Pike was looking at the garden. He usually waited until everyone else had finished eating, then would sit and have his meal in peace and quiet. He was 45 years old, and had a history of bipolar disorder. He was due to be discharged soon.
Mr Pike hadn’t noticed a thing. I kept watch, wondering what was going through Jeffrey’s head. For five minutes his gaze didn’t leave Mr Pike. I maintained my vigil.
Slowly, Jeffrey rose from his seat, and casually walked towards his subject. When he was an arm’s length away, he lashed out and his fist caught Mr Pike across the cheek. I yelled out down the corridor for help as I stepped into the fray.
‘I’ll kill the little shit,’ yelled Mr Pike. I was standing between the two, with arms outstretched, holding them apart. ‘Why’d you fucking do it?’ Jeffrey shouted back and lunged at Mr Pike. I managed to hold Jeffrey back. His gaze fell on me. ‘Are you in it with him? You’re in this together.’
It was at this point that I realised just how vulnerable I was. It dawned on me that I was standing between a furious Mr Pike and an obviously acutely psychotic Jeffrey.
‘I’m sorry, Mr Pike, please don’t hit him back. He’s just a kid really. He’s really unwell. We’ll sort it out,’ I rambled.
‘He hit me. I’ll kill the little shit,’ Mr Pike said again.
‘I can’t let you do it. Let me talk to Jeff for one minute.’
‘Why’d you hit him, Jeff?’
‘He spat on my food.’
‘Jeff, no one spat on your food. I was watching the whole time, and I promise you, no one spat on your food.’
Jeffrey paused in his efforts to reach Mr Pike and thought my words over.
‘Jeff, you’ve trusted me before today. Remember, I see you each morning, and I show you my ID. You know you can trust me,’ I pleaded. ‘Just sit down, Jeff, please.’ He didn’t budge.
It felt like forever, but was probably only 30 seconds before the rest of the staff came rushing in, to find me standing with arms outstretched, holding back the antagonists.
‘You’re all in on it, you’re all together,’ Jeffrey said, before taking a swing at me. Before the blow could land, the ladies had Jeffrey immobilised.
Jeff was taken to seclusion and given a strong injection of medication to calm him down.
Throughout the whole affair, Catherine had sat open-mouthed, speechless and terrified. She stayed glued to me for the rest of the evening. ‘What have I done?’ she kept on saying to herself, to me, to anyone that would listen. ‘I don’t belong here.’
Psychiatric units like mine can be brutal at times, but they serve a purpose. For some patients, the psychiatric unit is a wake-up call. They realise just how lucky they are to be healthy and sane, with a future ahead of them.
Many of the patients here don’t have a future. Sometimes, in their lucid moments, they realise this, and some lash out. But for the most part, the patients have no idea of how lost they are. Perhaps they just don’t have time to think about it because their reality is already occupied with what’s going on inside their head.
With counselling and the support of family and friends, Catherine made it back to school. Her overdose was deemed a cry for help, rather than a genuine attempt on her life. I do know she graduated and went to university. I never saw her again. I hope I never do.
As for young Jeffrey, it took three weeks to get him back on track. By the time he left, there was no way you would have ever guessed just how sick he had been. As long as he stays on his medications, he should hopefully be fine. He went back to university to finish his studies.
I spent two years working in the psychiatric unit before I was ready for a change. I wasn’t bored with psychiatric nursing – how could I be? – but there was another area of nursing that I had always wanted to work in: the emergency room.
I felt ready for the challenge. The emergency room deals with everything, and I felt that my experiences overseas, combined with my broad experiences in various fields of nursing, especially with my recent ones in the psychiatric unit, would make me the perfect fit for it.
Rangi Nelson was a freezing worker. If you are unsure what that is, it involves killing sheep, cattle and pigs for a living. The hours are long, with the slaughter going on through the night during high season. It is the sort of work that breeds strong men, both physically and mentally.
Rangi had been working the evening shift and was on his way home. It was ten o’clock at night, and he was tired. Thankfully, at that time, the back country roads are deserted. Rangi didn’t have a car, or a motorbike, he had a 100cc moped – not what you might expect a tough meat worker to be riding, but he was trying to gather together enough money to put a deposit on his own home. He was sick of his family having to live in state housing.
The first 13 or so kilometres from the freezing works to the city were pretty much a straight line. The only hazard was a single pair of railway tracks crossing the road. The railway line was rarely busy – most people made only the most cursory of efforts to slow down. Aside from a sign with a picture of a train, there was no warning.
That night, Rangi was jolted out of his daze as a train came seemingly out of nowhere straight towards him. There’s nothing like a thousand-tonne train, loaded with coal and wood, hurtling towards you at 100 kilometres an hour, to wake you up. He managed to stop just in time.
Suddenly Rangi found himself slammed into the side of the passing train. A car had come from behind and the driver had not seen Rangi on his little moped.
I was in the emergency room when Rangi came in.
I had only just transferred from the psychiatric unit two weeks earlier, and I was still being orientated to the emergency room. I was working alongside an experienced nurse called Shona, and I was only counted as an extra and not one of the rostered staff. Only after two months could I be considered a junior staff member.
In those two weeks, I had already learnt new skills and gained valuable experience, but there was one thing missing, one thing which I felt it very important that I be part of: a serious trauma.
All the experienced emergency room nurses had stories to tell about traumas, times when they had got their hands dirty; when they had battled against great odds and triumphed over death. To be a real emergency room nurse, I needed to experience a serious trauma, I needed to work alongside a team of pros, beat the odds to come out a battle-hardened veteran.
When the call came through telling us that the paramedics were bringing in a man who had been hit by a train, I just knew I had to be involved. I know how horrendous that sounds, ghoulish even, but this is the way many emergency room nurses are, they love the action, the challenge, they want to prove themselves to their peers. The nurse in charge could see how eager I was and gave me the all clear to begin preparing for the action.
My mind went blank.
I tried to remember what I was supposed to prepare, but it was hard to think where to begin: you don’t often hear of people surviving being hit by a train. The only thing I knew was that it was going to be bad.
Fortunately, I remembered my ABC. As you might expect, ABC makes the basics simple. It helps you figure out what equipment you’re going to need.
A
is for
A
irway . . . But in this case, I didn’t know if the patient was intubated, or breathing on his own. I eventually managed to think of something useful and began checking that the oxygen was flowing, and the suction working.
B
is for
B
reathing . . . The patient might have a clear airway, but would he be breathing? And how well? Rapid and shallow? Slow and irregular? Would he be struggling? Would there be gurgling or other noises upon respiration?
I tried to imagine what sort of injury a train could do to a chest. A collapsed lung or pneumothorax seemed likely, which would hinder breathing. Technically a collapsed lung isn’t really a collapse of the lung. What happens is the lung is made up of layers, and the outermost layer connects to the chest wall or ribcage. In cases of trauma, for example a stab wound to the chest, air from outside enters through the wound, filling up the space with trapped air. The air can get trapped between the layers that make up the skin of the lung. This then pushes against the rest of the lung, forcing it into a smaller and smaller space. So you need a drain that creates a one-way valve, allowing this trapped air out, and relieving the pressure.
I grabbed the equipment needed to insert a chest drain.
C
is for
C
irculation . . . What would the patient’s blood be doing? Leaking out on to the floor, or squirting up to the roof? Maybe there would be no obvious wounds, but the blood pressure might be extremely low, which could mean internal bleeding. In terms of preparation, this meant making sure we had the necessary equipment to provide intravenous access: intravenous catheters, central line. We also needed fluids and blood transfusions.
Thankfully I was not left to handle the preparations alone. While I had been running around like a headless chicken, the other staff had notified the surgeon and the anaesthetist and arranged all the things that I had missed.
This was shaping up to be harder than I’d thought.
As the ambulance pulled into the bay, the adrenaline began to flow. Looking around at the surgeon, the doctor, the anaesthetist, the radiographer and the other nurses, I could see the signs of a rush as well: nervous laughter at a bad joke, last minute checks of equipment that had already been checked ten times, slight tremors in a hand as someone tried to draw up some medicine. Everyone was ready for action.
As the doors crashed open and the paramedics wheeled in the casualty we got our first sight of Rangi. Aside from the fact his head was strapped down and immobilised by a collar to protect his neck, there was no obvious injury to his face. He was awake and seemed to be breathing normally. This was always a good start. As we transferred him over to the trauma bed, the paramedics said he had a very severe leg injury but was otherwise okay.
All the same, the doctor began his inspection at the head. I knew this was what he was supposed to do,
ABC
again, but I wanted to have a look at that leg and I began to unfold the blanket that was being used as a bandage from around his left lower leg.
As I pulled the last blanket away from his injured left side, I let it drop to the floor. The leg was a mess – at least, what there was of it. There seemed to be a fair amount of the lower leg missing. I glanced down and was horrified to see quite a bit of it caught in the blanket I had dropped, along with plenty of blood and some shattered bones.
I didn’t know what to do. The letters
ABC
,
ABC
kept going through my head, but it wasn’t doing me any good. In a moment of madness, I considered brushing the blanket under the table as if nothing was the matter.
I was pretty sure Rangi wouldn’t appreciate me asking him what he wanted done with the remains of his leg. I thought of wrapping it up and disposing of it in the rubbish bin, but the surgeons can do a pretty amazing job at times, so it was worth keeping all the pieces and hoping they could put his leg back together.
It is moments like these that nothing can really prepare you for. There is no class at college that tells you what to do when you drop a patient’s leg on the floor; no acronym. The doctor suggested I wrap everything up and put it to the side for the moment. He then wisely suggested I get some more morphine.
Rangi was wide awake the whole time; he was even talking to the doctors and nurses as he was stuck with all manner of frightening looking instruments. I will never forget his reaction when the doctor explained what had happened to his leg. He was told that they could try to piece his leg back together, but there would be little point, he would lose it in the end.
Maybe it was the shock, but Rangi calmly replied, ‘Do what you have to do.’
Rangi was rushed to the operating theatre where they amputated the lower part of his leg. His life was changed forever. Even though I never saw him again, I do know he was eventually discharged from the surgical ward, to the rehabilitation ward, and then home.
Rangi could no longer work as a freezing worker, at least not in the near future, but he still had to support his family. New Zealand has a system where we can’t sue each other for damages. The driver who caused the damage would have gone to court and possibly faced a jail sentence, but could not have compensated the victim financially. Thankfully, New Zealand has an accident compensation system where the government provides money, as well as pays for the things needed to help Rangi gain his independence again. They can even provide money for retraining in a new job if needed.
As for me, I learnt two things that day. One: don’t be so eager to be in the thick of it, and two: even after half a dozen years of nursing, I still had a lot to learn.