The thin red line

He wouldn't talk to my attending or chief resident, forcibly pushing them out of his room that morning, threatening to go combat style on them. "I've seen things you've never even imagined! I've done things you wouldn't think possible! I will hurt you!" he yelled at their retreating backs.

I was told to try again in the afternoon; maybe he would be a little nicer after he got more rest and some food in his belly. "But interview him out in the group space...he's here for homicidal ideation, after all," my attending warned me.

So around 1pm, I headed over to that patient's room and knocked on the door.

ME
Excuse me, Red?

PATIENT
Who the hell are you?

ME
I'm Michelle, the med student on your care team.

PATIENT
Student? Stop right there. I ain't having nothing to do with no students. I'm not some guinea pig for you all to experiment on.

ME
No sir, I'm not doing any experimenting - I just wanted to talk with you and see why you're in the hospital.

I smiled, trying to convince him that I was harmless. But he wasn't having any of it and he got up from his bed and started moving towards the door, presumably to close the door in my face. I started to back away, because even though he wasn't an especially large man, he was still cut a pretty threatening figure.

ME
Sir, truly - I'm just here to try to help you.

PATIENT
Help me? You don't know the first thing about helping me! You think you know anything about war? I've got some serious PTSD shit, and you think you can help me?!

Clearly, I had said the wrong thing. And he was angry now, yelling and swearing as he stormed out of his room into the common area. I apologized as I followed behind him. No, I didn't know what it was like to be in the army...but I did just have a lecture on PTSD by our residency director who used to work at the VA. Dr. Anzia? Perhaps he knew her?

He turned around to look at me and solemnly replied, "She's the greatest doctor that ever lived."

I nodded. He was calmer now, so I didn't want to say anything that might disrupt the milieu. He sank into the lab chair next to the nurses station. "You wanna know why I'm here? I'm here because in two days, it'll be the anniversary of something terrible. It'll be the anniversary of why I'm so dang messed up in the head. There was a helicopter accident. And everyone but me and three guys made it out. We lost everyone."

He started tearing up and his voice dropped to a whisper. All this had happened so many years ago, but it seemed like every little thing would set him off and send him back into those nightmares of war.

This time, he was walking along Michigan Avenue when he passed by a Vietnamese family. Seeing those children's faces immediately sent him back in time and he was reliving the terror. He thought he was back there, as he ducked behind planters on the street, jumping over railings, screaming at the top of his lungs, and generally just acting like a crazy person.

But he wasn't crazy; he just suffered from severe PTSD that had never been really treated. He was openly crying now, and feeling foolish standing in front of him, a towering giant in my 3-inch heels, I dropped to squat next to him. I thanked him for telling me his story, knowing how hard it probably was for him to relive it again.

We went through the rest of his psych and medical history quickly - finding out what pain regimen he needed for his terminal prostate cancer, what drugs had worked for his depression in the past, and lastly, what combo of drugs would work best for his PTSD. We finished talking about who he was seeing for therapy, and then after thanking him again for opening up to me and telling me his story, I went off to the med student room to write up my note.

I was proud of myself. I had taken this hostile patient and gotten some very pertinent information out of him. We had him on an antidepressant that he had failed twice before in the past, so we needed to change that. We had him on some Ativan but at such a low dose, it wasn't going to do anything for him. And he had bone metastases from his prostate cancer. Our current order - Tylenol for pain - clearly wasn't going to cut it for him. I sent a page to my chief resident, who texted me back with "strong work!" and I smiled. Maybe I am meant to go into psychiatry.

As I sat there typing up my note, happy as a clam, a nurse I had never worked with before knocked on my door. "Michelle, may I see you for a moment?"

My fellow teammate, whom I had excitedly told about my patient encounter, smiled at me. Clearly, she was going to praise me for having such a great bedside manner. He patted me on the back as I made my way out of the room.

NURSE
I saw you earlier talking to Red.

ME
[trying to be humble, but really, busting at the seams at what a great job I had done]
Yes. Are you his nurse? I looked on the board - I thought his nurse was Eva.

NURSE
No I'm not his nurse. But I needed to let you know that what you did out there in the middle of the room with Red was completely absurd!

ME
[shocked and honestly taken aback]
W-w-what?

NURSE
You were a pawn in his grand scheme! And you just ate it up, didn't you? Oh you young young thing. Red has been in and out of hospitals. I've been here for a long time and I can recognize that he's just here to get narcotics.

I sputtered, not quite knowing what to say. What had I done wrong? I know I'm pretty gullible, but my interaction with Red seemed genuine. He was crying, for chrissake! I hadn't taken him into an interview room, but that was on direct orders from my attending.

ME
Are you referring to how I was sitting next to the patient? I know that probably wasn't the safest thing, because he clearly could have punched me if he wanted to, but he was crying, and I really didn't think he was a threat --

NURSE
No! But that's another thing! He's a Vietnam vet! And you! You are this young Asian female, basically prostrating in front of him. Worshipping him! He was clearly enjoying this. You were right in the palm of his hand! Like a slave or concubine! I'm not saying that you are...but really. You were so subservient...ending the interview with a "Sir, is there anything I can get you before I go?"

I was shocked now. I would have understood if she were concerned about my safety. I would have understood if she had witnessed me crossing boundaries. But everything I had done seemed right in the realm of medical care. And honestly, I was a little offended. She had just compared me to a concubine! If that wasn't crossing a line, I don't know what is.

But I'm a med student, and we are the bottom-feeders in this hierarchy. So I gritted my teeth and smiled at her.

ME
Thanks Lee for the advice. I can see that you were worried about my safety, and I appreciate that.

NURSE
Now, no hard feelings between us okay? I'm just looking out for you. You're so young, you know. So young. If you have any more questions about anything, don't hesitate to ask me!

ME
Oh, I won't.

I smiled fake-sweetness at her and then went back to the med student room. My teammate whooped when I walked in the door, "Yeaaaaaaah!!! Did she just give you an honors guarantee??" I shook my head ruefully and told him what had just happened. He was shocked as well, "You know what? She wasn't there for the interview. She doesn't know what was going on. She's not even the nurse on our side! What the heck. She has no right to talk to you like that! And I can't believe she kept telling you that you were so young. Ugh. You should have been like, well, you're SO old! The old hag!" We laughed. I thanked him for making me feel better about myself, and then turned around to finish my note.

I still don't quite know what to make of it all. Looking back now, I realize I must have done something that set of the nurse's Danger radar. But what was it? Maybe I was squatting too close to the patient - he had been whispering after all. Maybe I should have excused myself to get another chair. And when he was crying, maybe I shouldn't have paused and patted him on the arm when he got choked up telling his story. There is a no-contact rule in psychiatry after all.

But at the end of the day, I have to remember that one of our psych lecturers told us we have to trust our gut. And my gut was telling me that this patient had been through a lot. He was angry, but for good reason. My gut told me that what this man needed at that moment was an ally. Someone who believed him and didn't think he was merely drug seeking. Someone who would listen to his story and emphatize. Sure, there are things I could have done to have made the situation better. But looking back, I doubt I would have changed anything. Regardless of what the nurse thinks she saw, I know that I was being professional but caring at the same time.

I might not be the best psych med student, but hey, at least I'm not jaded yet.