Browns Mills, New Jersey, United States
One flew east, one flew west
And one flew over the cuckoo’s nest
– Ken Kesey
The cacophony of egregious expletives coming from the crisis reception room astounds even the seasoned psychiatric staff working the hospital swing-shift. All spit and vinegar, the diminutive woman at the center of the staff’s concerns reaches deep and erupts in a plaintive caterwaul, echoing through the corridors of the Behavioral Health Unit with a primordial soprano of heart-rending grief.
As I arrive with a shot of emergency medication, her vitriol has subsided, somewhat, to the jibber-jabbering word-salad glossolalia of a Pentecostal rap artist speaking in tongues.
Leading the intake interview with his soothing demeanor is my peer and dear friend Brice, a nurse with twenty years experience whose ideas of relaxation are whitewater kayaking and composing overwrought poetry.
Brice dismisses the posse of sheriff deputies and military police surrounding the patient who are more than eager to depart, then stops me and the medication at the door with a subtle hand signal to stand by. Biding my time I review the police report.
The report states that our very impatient patient, Stella M., “flipped out” when her cadre of non-violent tree huggers were arrested while defending an old oak forest from from a planned expansion by the local military base. She required physical restraint. Allegedly. When Stella’s common law husband tried to come to her defense he was carted off to jail, their three-year-old daughter was taken into child protective services, and Stella arrived at the hospital emergency department for medical clearance. Previous admissions list Stella as a thirty-five-year-old unemployed Jewish female, with a dual diagnosis of schizophrenia and polysubstance drug abuse. An emergency room psychiatrist certified Stella gravely disabled and a danger to herself and others. The tranquilizer trifecta.
In Brice’s admission note, she describes Stella as pale, malodorous, handcuffed and aggrieved. Her hippie clothes and long blond dread locks are disheveled and dirty. Her responses fluctuate from incoherent duress to catatonic to brief moments of relative lucidity, when all she emphatically repeats is, “Please, I just want my daughter, and my trees, please.” Her occasional involuntary facial contortions, twitching, and vermicular rolling tongue movements, called tardive dyskinesia, are irreversible side effects from previous major anti-psychotic tranquilizers.
She is pregnant, second trimester.
One week into admission, Stella and her vacillating agitation has improved not at all. If anything…worsened. Convening, the multi-disciplinary treatment team of nurses, doctors, social workers and therapists agonize over Stella’s plan of care and finally propose a reputedly potent new anti-psychotic medication to be given orally. A minority of the team vigorously disagrees, questioning the as yet unclassified side effects of the new medication on her pregnancy. With the disagreement over the benefit-to-risk ratio escalating, one team physician Doctor Gestalt, objecting, refuses to prescribe the medication. Brice agrees with Gestalt. The majority of the team, along with the hospital administration, do not.
Fraught with legalities, the administrators summon the Bioethics Committee to mediate. The committee orders additional consultations with an obstetric specialist, a pharmacist, Stella’s public guardian, and, being a church run hospital, the religious hierarchy- not one of whom objects to the medication.
“Best of both worlds,” Brice quips sarcastically, “heartless science and mindless religion.”
Stella remains patently agitated. And with no committee resolution in sight, the dispute goes to the municipal court judge. The judge, after the briefest review, capitulates to the majority recommendation. “The drug may be administered.”
Doctor Gestalt promptly resigns from the case and, as the situation escalates, quits the hospital altogether. Doctor Kowalski assumes control of Stella’s case, and just as promptly writes the prescription for the hopefully effective drug to be given.
Stella, as the saying goes, may be crazy but she is not stupid. Clutching her growing belly she refuses to consent, exhausting herself on a master’s degree in histrionic vehemence.
Cringing, Brice paces the medication room, declining to as much as offer or encourage—never mind connive or coerce—Stella into taking the pill against her will. Storming the unfashionable moral high ground, he plots an assault on the legal decision as part of what he calls ‘a nursing care plan of attack’; including his written disclaimer of professional liability for Stella’s case submitted to the hospital board of directors. The disclaimer—I should have guessed—is a poem. He may be stupid, but he is not crazy. According to federal labor law, Brice says that if the hospital initiates disciplinary action against his defiant position, then they must officially respond to his disclaimer. Every amateur poet’s dream: a captive audience!
As Stella, refusing the medicine, only decompensates further, Brice launches an appellate litany of counter-arguments at the bioethics committee. “It is not rocket surgery, People!” Regardless of how toxic the new prescription may or may not be, basic nursing protocol mandates that we employ every less potentially harmful treatment, first. “For instance,” he harangues Kowalski, “how about increasing her occupational and physical therapy? Order a one-to-one staff ratio, or for that matter two to one. How about milieu therapy; sending her home with a visiting nurse on a trial basis; see how she does with her daughter, and her trees?”
“OK,” concedes Kowalski, “who is going to pay for all that? Or assume responsibility when none of it works? You?”
Impassioned, Brice switches tactics. “Haven’t we learned anything since the iconic movie One Flew Over The Cuckoo’s Nest won how many Academy Awards?”
And there it is! Like an epiphany into Brice’s recalcitrance I remember that he trained, straight out of college, on the same unit of the Veterans Medical Center where Ken Kesey, working as an orderly, earlier penned the seminal text to the movie excoriating the mental health system at the time. And which B. never recounted without a mischievous glint in his eye.
On Brice’s next day off from work, Kowalski does indeed write an order: for two additional anti-psychotic medications that can be given by injection, with or without the patient’s consent.
With the adverse side effects of both additional drugs classified as definitely dangerous on the scale of fetal toxicity, the expedient rationale—or loophole—for their use, according to the majority, is that her agitation, left untreated, might be even more damaging.
That we might be a cause of the agitation somehow escapes the equation.
Stella is cornered, restrained, taken down, and injected.
Returning to work seething with incredulity, Brice rears into a tirade of patient advocacy to the point that I worried they were going to medicate HIM. “A loose cannon on deck,” goes the narrative through the grapevine, dismissing Brice as “an antinomian Don Quixote, with a Freudian Oedipal Complex projected on the powers that be”.
Tripling his nursing care of Stella, (Stella by Starlight, as he jokes with her), he desperately engages her in one-to-one counseling sessions, and experiments with the flower child music and aroma therapies she loves so much. And, yes, as I had to admit to the Disciplinary Board, even to the neglect of his less acute patients. To top it off he enlists nurses from the Obstetric Department to monitor Stella’s fetal heart tones and pre-natal care. Without hesitation kindly nurses Betty Ann, Sandy, and Rhoda take turns, coming every day.
“Exactly how onerous is that chemical cocktail to her pregnancy!” He asks anyone who will listen, antagonizing the treatment team to no end with the rhetorical question. Rhetorical because nobody honestly knows the answer. Not the researchers, not the manufacturer, not the FDA. He makes a good point; few staff really want to tangle with a pregnant wild woman anyway, and an undercurrent of mutinous murmurs makes the rounds. Mixed emotions and professional resentment split the staff.
Until, that is, the written directive from the hospital administration arrives forthwith. “The failure to comply with any and all [legal] doctor’s orders is grounds for disciplinary action up to and including termination from employment, and revocation of state licensure.” At that point the wavering staff visibly distance themselves from Brice and his dwindling co-conspirator’s uncompromising stance.
Stella, however, displays preliminary signs of marginal recovery and is quickly discharged.
Not one month later, under the guise of fiscal cutbacks the administration reduces Brice’s work hours to a financially impossible two days a week.The last time I saw him, he was with the tree huggers defying the planned military base expansion.
Three months after that, Stella’s baby was born at our hospital.
The medical chart declares Stella’s labor and delivery uneventful and the baby normal. In attendance, the obstetric nurses Betty and Rhoda, however, had more to say on the subject. Over a cup of coffee in the hospital cafeteria, they explain to me that only time will tell about the baby’s occasional little facial twitch. But otherwise the Apgar Assessment Scores were fine: a healthy seven pound, rosy-pink, bouncing baby boy who the parents named Brice.
Absently scanning Stella’s chart with a tear in my eye, Ifind the poetry disclaimer, trying to laugh as Nurse Brice insists “It is not rocket surgery.”
The Staff of Aesculapius
From the ancient medical myth of Chiron
to the gospel Sermon on the Mount
From the Hebrew Covenant in the Wilderness
to the esoteric elaborations of Kabballah
From the voluminous Hindu Bhagavad-Gita
to the Buddhist’s Four Noble Truths
Amulet to Crucifix, Oak Grove to Cathedral
First and last: the alpha and omega of holistic integrity:
Primum non nocerum
First do no harm
MATTHEW KINSELLA, LPN/VN, OSF, resides in Browns Mills, New Jersey. As the saying goes, old nurses never die, they just look that way. As a bedside nurse for forty-three years, Mathew Kinsella observed great strides in the ethical treatment of our most vulnerable patients. The true story of STELLA hopefully contributes to that trend: a gentler and kinder therefore more effective healthcare milieu.