Interventional Psychiatry

This work of fiction is intended to satirize the growing trend of “interventional” subspecialties and the pervasive impression of psychiatry as a “hands-off” field of medicine, and also to caricature societal and medical expectations that psychiatrists can, and should, be held responsible to predict and prevent patients’ attempts at suicide and self-harm.  Evoking tropes of the “Hardboiled Detective,” the “Femme Fatale,” and “Private Eye Monologue,” this short story draws inspiration from film noir and pulp science fiction. It is best enjoyed “chilled” with chiaroscuro lighting, a scotch in hand, and smooth jazz on a rainy evening.

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Watercolor: “Akathisia #1” by Alexandra Ewenczyk, MD

I’d just settled in for the night and put my feet up for a marathon therapy session with an old friend I’ve been increasingly out of touch with since our college days, though not for lack of trying.

My name’s Quill. Sara Quill. My patients think I’m their life coach. My colleagues think I’m a patient. I’m a psychiatrist; the tweed jacket and round reading glasses say it all.

The call came in just as I reached for two measures of jazz, one classical and a dash of the blues, the closest I get to a cocktail working nights. The patient was well known to the system, a guy who gave the term “frequent flyer” an entirely new meaning after three suicide attempts jumping from highrises.  I didn’t need my bookie to tell me the odds on this one.

I dropped the phone and grabbed my partner. He’s the strong, silent type. He takes orders as fast as I can write ’em, knows his monoamines and neuroreceptors like nobody’s business. We’re joined at the hip; he rides in a holster and calls himself “Pyxis.” Damned if I know where that came from.  He usually lets me do the talking, but when things get rough, he’s always got three simple arguments to make things right: haloperidol, lorazepam, and diphenhydramine.

My VTOL aircraft smashed through the night rain as we flew across the city skyline faster than pressured speech on cocaine.  Red and blue sirens scattered civilian traffic as easily as I burned through my warranty flying on 150 kilonewtons of high bypass thrust.  The old bird was thirstier than I was at the end of most nights. Tonight’s dry cleaning bill wouldn’t help either.

En route, the thought to call the patient’s contacts to gather collateral information crossed my mind, but my last conversation with my loan officer and the collateral he demanded left a bitter taste in my mouth. I wrenched the VTOL’s door open at the destination coordinates, the roof of the skyscraper ten stories down leaping into focus.  

Our boy was on the edge of the roof. I took his toes hanging over the ledge and his spread-eagle arms as poor prognostic signs. Screw it.  Psychiatry isn’t the kind of job you choose if you want all the facts and a solid game plan ahead of time. We just do, evidence-based or not.  

I took a running jump and leapt from the VTOL, Pyxis firing drop-gas slugs. A cloud erupted beneath me with fog thicker than a Victorian movie set as I fell down to the rooftops faster than I bleed chips in a poker game.

I’d timed my jump perfectly, landing behind the patient in a three point stance, tweed coat billowing and lashing in the rain and lightning as the gas blew off, Pyxis drawn.  

“Psychiatry!” I shouted over the storm as he turned to face me.  “Let’s talk this through!”

He gave me a story he’d probably repeated a hundred times.  He was going to do it, he told me, just like all the other times.  SIGECAPS, the diagnostic criteria for major depression, was practically tattooed on his forehead. 

“Sign in!” I called back, taking a few steps towards him, “Or we do this the hard way.”

 

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Watercolor: “Akathisia # 2” by Alexandra Ewenczyk, MD

The man closed his eyes and shook his head, sharing a piece of his mind. He had nothing to look forward to. No reason to live. No one left who cared. You didn’t need four years of postgraduate medical training to see the facts as he shifted his weight and let gravity do the rest: those things were probably true on his way up to the roof, but at least one would be false on his way down.

Time crept slower than the neurological exam of a geriatric patient on topiramate. I sprinted across the rooftop and threw myself over the ledge after him, pitching and tossing in the rushing air as I reached for his rag doll arm in the flashing red and blue lights of the police cordon beneath rushing to meet us.  

Grabbing hold, I fired gas slugs as fast as my Pyxis could dispense them. We dropped into the rising cloud, both alive, if not necessarily in a collaborative agreement or therapeutic alliance.

The gas dissolved around us as fast as my patient did to tears, bawling and cutting loose with a disorganized stream thoughts detailing everything wrong in his life and why he had to jump.  I picked myself up, straightened my coat, and nodded to the officers who took him into custody.  

“Sir,” I said, cutting off his ruminations and handing the officers my assessment and petition for his involuntary psychiatric admission, “I work in crisis. Tell it to your inpatient psychiatrist.”

Albert Yu is a first year psychiatry resident at Penn.