To be known: Trust as an antidote to poison

Maddie Mulkern

Before coming to medical school, I worked for three and a half years on a geriatric psychiatry unit. It is a role that I remember fondly, one which sparked my interest in becoming a doctor by honing my interest in the many conditions that affect the brain, as well as the therapies available to help treat them. Equally as important, this place was the origin of my love for Bingo and Wheel of Fortune, as both were quite popular on the unit. These games served as a backdrop for many excellent conversations despite the generation gap between myself and my patients, many of whom had grandchildren my age.

My official job title was listed as a Mental Health Assistant, but this role was near ubiquitously referred to as a “counselor” on the unit floor. Being a counselor entailed distributing meals, performing various hygiene-related care tasks, and organizing the large hallway cabinets filled with blankets and hospital gowns. It was a far cry from the chaise lounge-bound therapy sessions one might typically associate with counseling careers, but this role was nonetheless transformational in my understanding of patient care. 

On the unit, there was a semi-stratified order when it came to the members of an individual’s care team. While everyone worked together towards the common goal of healing, there was a gap in patient interaction between the staff who spent their shifts in the same space as the patients and those who sat behind locked office doors or typed away at the Pyxis machine in the medication room. Physical therapists, nurses, doctors— it seemed like the more training one had in patient care, the less time one actually had to spend with patients day to day. Countless conversations were condensed into mere 15-minute windows, with professionals whirling through the floor in hurried attempts to keep on top of their packed schedules. 

On the flipside, here I was, with no previous medical training, working supposedly as a counselor despite never having counseled anything in my life. Nevertheless, I enjoyed my work immensely. I spent most of my 8–12-hour shifts in close proximity with the patients in my care, gradually building relationships with them through friendly Bingo games and light small talk in the milieu. My face, which popped into each room during mandatory 15-minute interval safety checks, became a common sight to everyone on the unit.

This pleasant routine characterized many of my working hours. But I doubt I would be in medical school if all I had experienced were the mundane and not very stressful parts of my job. The nature of the psych unit, however, made sure to keep me on my toes. On one fateful night, I was minding my business restocking the toiletries cabinet when I heard a scream. It was the sound of my own name, ripped from the throat of a terrified woman sitting at the other end of the hall. The noise was so sudden and shrill that I thought someone’s heart had stopped. Mine nearly did from the surprise alone! 

Without hesitating, though, I rushed to the source. There I found one of my patients, sitting tense with anxiety in one of the oversized chairs in the main hallway. When I stopped at her side, she lowered her voice to a fearful hush. 

“Take this,” she whispered, pressing a crumpled piece of paper into my palm.

Following her directions, I took the paper, discreetly unfolding it so that I could read its contents in relative privacy. There, shakily scrawled in pencil, read the following message:

CALL 911. THEY ARE POISONING ME.

Oh no.

Even without a strong foundation of medical knowledge at that time, I knew that this patient was suffering from psychosis. I knew that the ‘they’ she was talking about were the nurses, and that the ‘poison,’ she had been given was most likely her nighttime medication. I knew that this patient’s perception of reality was distorted, warped by the condition that had brought her to our unit in the first place. But looking down at her while she sat, I knew that she was also in real distress. She was crying, her body language tight with fear, her breaths rapid with a budding anxiety attack. The poisoning, in her perception, was genuinely affecting her, and that reality was nothing short of terrifying.

I knew I had to do something… but what could I do?

Calling 911 certainly was not an option. Still, there was an option to recruit additional help: I could have gone to the nurses and suggested that she receive additional anti-anxiety medication. However, I decided this would not be a good first step. In her current state, one that characterized the nurses as potentially murderous, bringing them in might have only served to scare and upset her further. The patient, caught in the pits of paranoia, had extended fragile trust to me by placing that note into my hands. I wanted to make sure that brave act of reaching out and asking for help would not be a mistake. 

So I reached out to her in turn, sitting next to her and taking her hands into my own. I calmly let her know that I would not be calling 911, but that I would monitor her condition closely and sound alarms if I noticed any kind of emergency. Then, I simply stayed by her side, sitting hand in hand until her panic subsided. The one time I left was to grab her some tissues and water to “help flush the toxins out,” trying to soothe both her mind and her then-dehydrated body. By the time her tears had dried, she was more comfortable, and ultimately able to set aside the belief that she had been a target of a poisoning attack. In the days that followed, she returned to common areas that she had previously withdrawn from, calling out guesses to words on Wheel of Fortune with the rest of us.

As medical professionals, we must strive to build trust with our patients. Admittedly, some kinds of paranoia are unavoidable and difficult to manage, especially in psychiatric units. Even so, I believe that this case could have been handled even more effectively if my patient trusted staff at all levels of her care team, not just the ones that she saw organizing bedsheets in the closet outside her room. My position granted me the unique benefit of time spent with patients, time that allowed me to build rapport with them. In many situations, physicians can feel like that kind of time escapes them. As their professional responsibilities grow, they lose the ability to discuss issues beyond chief complaints and clinical assessments. But little moments and small talk matter to people, and even the tiniest acts of kindness can leave a massive impact on those who receive them. Whether it is through a bright smile flashed at those passed in the hallway, or the act of holding someone’s hand in their darkest moments, one can make a difference in somebody’s life just by reaching out. After all, trust is what makes for the foundation of care, and to be trusted is to be known.

Maddie Mulkern is an MS2 at UMass Chan Medical School who is interested in neurocognitive care. They are currently one of the co-presidents of the UMass Chan Geriatrics Interest Group.