The Insane Man

It was just before closing at our small Mom & Pop Urgent Care Clinic, 7:30 PM on a very slow, almost-autumn night. At my desk in the back office, I suddenly heard rapid, loud speech aimed at our receptionist at the desk out front, full of disturbing content.

 “I need to talk, to tell, to confess, I’ve done bad things, don’t you look at me with fear in your eyes!”

 I hurried to the front and went into the waiting room to assess and address the speaker. I could see our usually smart-aleck receptionist, Cammy, looking dismayed.  Lakeisha, our city-raised streetwise medical assistant, her eyes round, was leaning way back in her chair, away from the “patient”.

I greeted the compact, muscular man. He looked to be in his mid-twenties. 

“I am Dr. Lyons; can I help you?”

 He turned towards me, and a torrent of agitated words streamed from his mouth. He was keyed-up, clearly manic and menacing in bearing and tone. He needed to be seen, immediately. He was upset. He needed a doctor. He had ready money and had to be seen straightaway, no matter what.  I asked what was troubling him so keenly.

 “I need to talk, I’ve hurt people.”

 “Are you worried that you might hurt people now?”

 “Nah, doc, that won’t happen.”

I felt a little better. I considered. If I refused to see this man, I feared he would erupt, and we were five women alone in a free-standing Urgent Care Clinic.  I wondered how much damage he might be able to do before the police could arrive. As I’d hurried from the back hall towards the front, Tina, our X-ray tech, had grabbed my arm. She’d whispered that there was only one other patient left in the facility. His vitals had been taken and he was now waiting in an exam room. It was the shouting man’s older brother; 6’4”, 245 lbs.

The older brother, who had appeared well, comfortable, and determined, was by report complaining of migraine and asking for narcotics. So, we had one frightening man in the front waiting room, and his drug-seeking sib already ensconced in the back-hall exam suite—we were clearly deep into this situation. We had taken a co-pay from the older brother who, despite our perception of his motives, had done nothing amiss. There was no way I could possibly undo these fellows’ presence here, and if The Insane Man became more erratic when I refused to see him, upon whose side would his brother be?

I thought. I felt that I had little choice. I had to see this man. I asked him to please sit in the waiting room while we prepared a room, but he was unable to sit still and re-approached the reception desk, talking non-stop, eyeing Cammy and Lakeisha.  Lakeisha fled to the back office. Cammy remained frozen behind the desk.

A brief whispered tense strategy session ensued in the back hall with my staff, away from both patients’ sight and hopefully, hearing. I instructed Maria, our nurse practitioner, to see the brother and “give him whatever he wants” in terms of narcotic prescriptions, and “just get him out of here”.  Neither patient had seen Tina, the X-ray tech, and her job was to stay hidden and call the cops; to ask them to please come now without lights or sirens, to be present if something went wrong.  We did not want the two brothers to hear or see police vehicles/lights approaching and become alarmed or desperate. Tina’s husband was County Police, and although she was timid, she understood the drill. She nodded her head, yes, grimly.

Lakeisha appeared nearly paralyzed. She had told me last year, in confidence, that she and her best friend been stripped and robbed at gunpoint 4 years earlier.  Despite her oppressive fear, she stepped out back into the darkening parking lot and recorded the make, model, and license plates of the brothers’ two automobiles. Why had they driven two cars? Ominous possibilities filled my head.

I arranged the exam room. I pushed my patient’s chair back against the wall in the part of the room furthest from the doorway. I would sit close to the doorway, my chair turned sideways, door open, so I could flee at a moment’s notice. Even so, the seats of our chairs were only a couple of feet apart in the tiny exam room. Disconcerted, I was suddenly distracted by the fact, never before considered, that all our examination room doors opened into the small exam cubicles. If I ran into the outside hall I couldn’t push the door shut, lean on it, lock it, to contain any interior threat. I would have to try to pull it closed behind me. Not ideal. I thought about the strength of my patient’s arms, and the relative weakness of my own.

I brought The Insane Man back to the exam room myself and asked Lakeisha to stay away. She would normally have checked our patient’s height, weight, blood pressure, temperature, pulse and respiration rate. This man was not patient, and I didn’t want Lakeisha near.  No vitals were taken. I didn’t want to further stimulate this man by having anyone touch him.

In the room, my patient’s anxious harangue became a firehose burst, displaying just how poorly and fantastically his brain was functioning. He spewed out urgent snatches of skittering thought referencing the Koran, the Bible, martyrs, murderers, and saints.  He described, chillingly, and in detail, his self-created violent “art” and rap lyrics. He apprised me of the “fact” that it was “wrong to hurt innocent women and girls, people, but sometimes you just have to”. He told me that he found the women staffing this clinic attractive. He never blinked. I heard how this man could harm people with his thoughts.  I learned that his older brother tried to “smooth him out” with marijuana but that sometimes the patient’s patter would excite his brother and they would then “do things” together for which they were later sorry. The Insane Man’s main theme was his desire to commit sexual violence, and his struggle to refrain from doing so. He also told me he wanted to be a hero, and atone for past wrongs, and to try to love others despite their racial and religious differences. He explained he was trying to be a better man than he had been in the past. He spoke earnestly and lovingly of his older brother. His brother had protected him from their abusive father. His tone and mood turned on a dime, first threatening, then beseeching, then preaching, then sorrowfully impassioned. At times, he spoke almost normally, only to bray out loud laughter at jarring intervals, apropos of nothing.

I strove to maintain my calm and attempt to connect in an open, helpful way with this patient, now my patient, sensing it might be the only way to end this encounter peaceably. Inside I felt terrified and guilty. I had made the decision to see this man, and if he and/or his brother harmed my co-workers or me, it would be on me.

I asked him if he needed to go the hospital.

 “I wouldn’t have come here if I thought you were going to threaten me with the hospital—I can’t go back there again,” he spat angrily. 

He was all over my body language.

“Hey Doc, relax, loosen those shoulders, take off your glasses so I can see your pretty eyes.” 

During the next fifteen minutes we negotiated in the brief intervals in which he appeared most lucid. My glasses stayed on. We agreed that I would give him a prescription for his anti-psychotic/bipolar medicines and some sleeping pills.  I explained that I was powerless to deliver the marijuana that he demanded, as I was not licensed to prescribe it, but perhaps, if he called his psychiatrist in the morning, she might be able to assist him. I tried to wrap things up, to no avail.

 “I haven’t had my money’s worth yet, don’t you dare cheat me,” he hissed, leaning forward into my space.

I explained that we had only ten more minutes, that the facility would close, and that my boss demanded that we close on time. He understood this.

“Yeah, I got a boss too. It’s my Dad.”

At this point, tears streamed down his face, and he choked, drooled a bit, then seemed alarmed.

 “Am I sick?”

 I explained that he had tears in his eyes.

 “Wow, I didn’t even realize I was crying.”

He wiped his mouth with a tissue I gave him.  He looked at the saliva. 

“Is it blood?”

I reassured him, “No, you are ok, it’s just spit.”

Finally, he seemed to come to some inner decision point, a few minutes before our allotted “session” was to be over. He leaned forward again, and I had to consciously strive to relax my tense muscles and not flinch away.

“Now you tell me doc, you heard me, you tell me, tell me what you think of me, you just better tell me what you think right now, you judge me, and then I’ll judge you.”

He now appeared excruciatingly focused, poised upon some inner precipice. I was knifed by the abrupt certainty that this was the instant where I could either defuse or set him off.  This moment required brinksmanship of a higher order than I had ever before attempted.  I thought of past mistakes and decided upon my strategy. 

I concentrated my hardest on seeing my patient only as a mother’s son, only as a former frightened child; not as the driven, agonized, monstrously malfunctioning man I saw before me. I fixed my mind upon this inner empathic vision and allowed the emotions it elicited to flood my pounding heart. I used those feelings to temper my choice of words and tone. I let them bleed into my facial expression and soften my muscular tension.

I cleared my throat; my Insane Man was clearly not stupid.  I knew he was perceptive enough to detect bullshit. He had told me as much:

“I can tell when people lie to me, and I don’t like it.”

I believed him. I told him a limited truth.

“I think you were born with a good heart. I can see that you are hurting. I think that I can give you these medicines to try to help you,” I gestured towards the prescriptions I had written for him, “I think you should call your psychiatrist in the morning.”

He agreed.

“I like her, she’s pregnant.” 

He stood, grabbed the prescriptions, and exited the room. Providentially, his brother walked out of the exam room opposite at the same time and wrapped an arm around The Insane Man’s shoulders. The older brother was happy with his script for Percocet. They sauntered down the hall towards the exit. I followed at a short distance, just out of arm’s reach.

My heart beat a bit easier, then froze, as my patient halted, wheeled, faced me, and leaned to within three inches of my face. He smiled with ghastly intensity. I could feel his breath on my face. His eyes bored into mine.

“You did good here Doc; when I need something again, I’m gonna go find someone who looks just like YOU.” His brother touched his arm as he shouted the last words.

“Hey, it’s okay Aadam, let’s go. We’re done here.  Khoda hafez, Doc.”

They left. I locked the door, hurriedly. I called the police, again, to tell them that the obvious threat had passed, as they had not yet arrived. When the cop car drove up five minutes later, I reported our encounter with the responding officer. I feared for the poor pharmacist who would fill these fellows’ prescriptions, for men and women on the street, for anyone who crossed these two.

As the officer called the station on his walkie-talkie, I found my whole staff in a small knot in the breakroom. They had heard everything through the open exam room door and the thin office walls. We were all shaken and trembling. I was embarrassed to cry a little in front of them. We comforted each other. We hugged and made weak jokes and shored each other up. We felt rattled, but lucky.  The cop who responded to our complaint graciously walked us all to our vehicles in the dark back parking lot.

It wasn’t until the next morning that I was able to reach The Insane Man’s psychiatrist, as the practice had no overnight call service; it directed patients with urgent needs after office hours to go the ER. The Insane Man’s psychiatrist had seen him two days ago, with his mother.

“The family tries to keep him under wraps. He was manic as could be when I saw him on Tuesday but he wasn’t saying anything that would allow me to commit him*, but with this new information, we can try. He feels worse on his meds, so periodically he stops taking them.” 

To her knowledge, he had never actually acted out on his violent fantasies—as an adult. He did have a police record.

“Yeah, he was in juvie for four years, but those records are sealed. I’m almost glad I don’t know what’s in them; the family hints that he did something terrible.”

 Hearing this his did nothing to alleviate my concerns.

“Please, be careful,” I urged, “He talked about you and your pregnancy.” 

“Yeah, I know, he says he can impregnate women with his eyes.”

We agreed that I would fax over my office notes; the documentation of my clinical assessment of The Insane Man’s condition the night before.

My co-workers’ boyfriends and husbands were concerned, as was my own mate. On the way to work next day I stopped at Walmart, and for good or for ill, purchased a wooden Louisville Slugger to keep under our reception desk.  Our male boss stayed late that night to be with us till closing.

I don’t know what became of The Insane Man. I never saw him again. Part of me wants to know that he is safe, back on his medications, and another part of me wishes he were gone from the world. I don’t know how to feel about our encounter, but I feel, deeply, nonetheless.

At home, very late that frightening night, I walked out into our backyard in bare feet, and peered at the twinkling stars, at the incandescent crescent moon illuminating the sky. My precious family was asleep, and I wondered if God did truly exist, and if so, did God care about small souls like my own, those of my staff, that of the psychotic man who had frightened us?

I realized that I was angry in the aftermath of this alarming encounter. I felt mentally and emotionally bruised, and was furious, knowing that I had been in danger, along with my co-workers. Tonight we had been in peril despite, and actually due to our vocation of healing. I wondered if I was a fool for my persistent, unprovable faith in an ultimately benevolent deity. My co-workers and I had managed to navigate this encounter unharmed, but I had newly glimpsed how thin that veneer of safety might really be.

Tonight, I had seen an insane, charismatic man whose plight of brain disorder I could empathize with, despite the fact that he was an unbalanced powder keg. In outraged bewilderment, I prayed. I prayed furiously, impotently, for the unlikely healing of The Insane Man, and I begged God with the insufficient ferocity of my shaken soul to protect unwary innocents in this tortured man’s path, and to guard those I loved, worked with, treated.

I considered for a long while, simmering down, then, more calmly, thanked the powers that be that tonight’s encounter had ended without violence. No voice, no deity, replied. I listened to crickets, owl hoots and the calming white noise of cars flying by on the distant highway. I allowed myself to become immersed in the rhythm of the surrounding, busy, wee hour world. There was no resolution from above, yet somehow, I felt comforted. Eventually, as the dawn broke above the horizon, I was able to lay down beside my husband in bed, and finally fall asleep.

Paula Lyons, MD

7/29/2020

*The Insane Man’s psychiatrist is referring to the rules regarding the Baker Act. Laws differ slightly in each state, but the Baker Act provides for the involuntary commitment of a person to a mental health facility for a short period of time (72 hours) for further evaluation and treatment. The Baker Act can be used if, and only if, the person in question poses an immediate, ongoing, and significant risk of harm to themselves or others