Voices of No Reason

I was asked to see a patient because he was HIV positive.

"Is it a new diagnosis?", I asked the intern who called me.

"No, he said he had it for 20 years, or 22, not sure, he keeps changing his story. He doesn't have any documentation with him but he has some bottles with HIV drugs. He was admitted last night for gastroenteritis. He's also schizophrenic, big time schizo, and he just came from Phoenix to Tucson and is not saying why. This guy's crazy, so if you can just tell us what HIV meds should we keep him on and if we need to check a CD4 count or other labs as well. Appreciate it."

I went to see that patient at the end of the day. It was around 6 pm. I intoduced myself to this 40-something dude, brought a chair and started chatting. I looked at him: he had a very abnormal face, which could tell his had some congenital disease. I tried to guess what it was but couldn't come up with something. If I had paid more attention in the genetics class in med school I might have been able to tell ( damn those Khateeb lectures were so boring).

Although I love talking to psych patients, I didn't feel very comfortable then. This guy had no facial expressions. I would ask him a question and he'd answer like a robot. No smile, no frown, no emotions in his voice. No emotions in his face.

I was done asking him about what I needed to about his HIV, then decided to go a little bit over the schizophrenia.

"So you have schizophrenia?"
"Yes"
"For how long have you had it"
"Two years"
"Do you hear voices"
"Yes"
"What do they tell you"
"They tell me to ........." and I couldn't hear well
"What?"
"They tell me to hurt people"
"What do you do when you hear them?"
"I obey them"

(I was impressed by the word obey)
"So have you tried to hurt people"
"Yes"
"What else do they tell you"
"They tell me to kill people"
"And what do you?"
"I obey them"
"Have you tried to kill people?"
"Yes"
"How?"
"With a gun, I have a gun"
"Do you have a gun with you now?"
"No, I left it in Phoenix"
"Why did you leave Phoenix?"
"Because I had a court order"
"Order for what?"
"Court order to take my schizophrenia medications"
"So you don't want to take medication?"
"No"
"Why not?"
"I don't like these medications"
"So for how long haven't you taken these medications"
"Long time"
"Do you hear voices when you take the medications?"
"No"
"So are you hearing voices now?"
He paused as if he was listening to someone else
"Yes"
"At this moment, are you hearing voices"?
"Yes"
"What are they telling you?"
Closing his eyes he answered, "lotsa things, lotsa things"
"Are they telling you to hurt someone?"

He paused again and looked straight at me, again without any facial expression. I started the process of crapping on myself, and wished I had stopped at the HIV part and left the room. It was dark, the room's door was closed and because it was the night shift there were only very few nurses around. I was 1-on-1 against this man. He was well-built, with a sign "6th street gangster" tattooed over his back, and quite a few scars on his face. I thought to myself if this dude jumps on me now and rests his big hands over my neck he can send me to floor minus two (the morgue) in 20 seconds and I will end up being a headline on the local newspaper.

Instead, he answered, "No" and kept listening to the voices and added, "they're not telling me to hurt people"

I left the room, as I opened the door I turned back and said, "Ok, nice to meet you sir"
I was not expecting a reply but he said, "Nice to meet you too"

I called his intern.

Intern: "So does he need HIV meds?"

"Yes, he also needs a psychiatry consult and you need to call the cops"

This guy may end up in jail for violating a court order, but they won't admit him to a hospital unless he was actively contemplating suicide or homocide. If he had thought of it a few weeks back they would still let him go back to the street.

Here's the equation: in our city of nearly one million, there are only 2 hospitals with very few beds reserved for psychiatry patients. Each night costs 500 dollars. Meanwhile there is much more room in jail, and a night there costs 10% of what a night in a psych hospital costs.

There's a reason why I don't like walking alone in the street and why I make sure doors are well-locked at night.