In the fall of 2005, I returned to medical training as a psychiatry resident at Walter Reed Army Medical Center. I’d spent the last four years overseas: most of one in the Persian Gulf on a ship, and then three years in Italy.
My third month as a resident, I spent on a rotation called Night Float. It meant I worked overnight, taking care of patients on the psychiatric ward, evaluating patients in the emergency room, and addressing any psychiatric concerns about patients on medical or surgical floors. During that time, I remember leaving for work on Halloween. Leaves were falling and young children were walking past with their parents, the first trick-or-treaters for the night. My family and I were happy to be back in America.
As the overnight psychiatry resident, I also evaluated psychiatric outpatients who arrived as medical evacuations from the two wars in Afghanistan and Iraq. The planes carrying casualties landed at Andrews Air Force Base at least twice a week. Most came from Iraq through the American military hospital in Landstuhl, Germany. By far, the surgical teams received the most patients, and most of those were direct admissions to the hospital. From what I recall, we received two to four psychiatric direct admissions with each flight. They came directly from the inpatient ward at Landstuhl. Some flights also contained one to two soldiers arriving for psychiatric care as outpatients, meaning a psychiatrist had considered them too ill to remain in a combat zone, but didn’t believe they required hospitalization. They weren’t suicidal or psychotic.
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One night, I don’t think it was Halloween, the casualty flight from Landstuhl included an outpatient psychiatric patient. I had to evaluate him to make sure he was safe to go to housing on the hospital grounds without close monitoring. He required a wheelchair, something unusual for a psychiatric patient coming from Landstuhl.
Sam, a previously healthy young man, had fallen from the top of some stairs while on duty in Iraq. Doctors there found no physical injuries, but he could no longer walk. A psychiatrist diagnosed him as having a conversion disorder, and he was medically evacuated to Germany. A further evaluation there still found no physical cause for his injury. So the diagnosis remained, and he came to Walter Reed for further evaluation and treatment.
Conversion disorder means that a psychiatric problem out of the patient’s conscious awareness is causing a physical impairment. Literally, a mental problem is converted to a physical one. It’s an unconscious process believed to come from an overwhelming mental conflict that the person can’t tolerate thinking about. People with them aren’t faking the problem. They believe they can’t walk or see or any other physical way it manifests. Indifference about the physical problem is a classic reaction in patients with conversion disorder, which, in my experience, isn’t always present.
Conversion disorders are believed to have been much more common a hundred years or more ago. They might be less frequent now because of cultural changes or a more widespread understanding of emotional stress. However, we’ve gotten better at diagnosing physical problems that in the past doctors believed were conversion disorders.
They happen. I’ve seen and treated them. They are more likely to occur in people with severely abusive childhoods and also in extreme situations where emotions can’t be expressed, such as combat. However, you still have to be very careful in labeling a physical problem as a conversion disorder. Even today, studies show that doctors eventually find physical causes for over half to seventy-five percent of illnesses labeled as conversion disorders. In my experience as a psychiatrist, a non-psychiatrist diagnosing someone with a conversion disorder means either that doctor is angry at the patient or doesn’t recognize his or her own diagnostic limitations. Some doctors don’t like to face that they don’t know everything.
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As usual that night, the medical evacuation staff brought all the outpatient arrivals to post anesthesia area outside the operating rooms. The hospital had no other place for them. A nurse with the Walter Reed’s casualty receiving team remained in charge of them and was responsible for placing them in housing on base the ones doctors didn’t decide to hospitalize.
I arrived there to evaluate Sam from the emergency room, where I’d just finished seeing another patient. Orthopedic, general surgery, and other residents were already evaluating their patients. They would hospitalize few of theirs, unless they found a severe infection or other acute problem. They mostly did quick checks and left. Our psychiatric evaluations took longer. I had to decide if I felt this person I just met would kill himself overnight if given the opportunity.
When I finished, all the other residents had already left. Enlisted staff escorted their patients to rooms on the hospital grounds to spend the night and then follow up in clinics the next day. Other than what I’ve already said about Sam, I remember little of his history. He was pretty tired from the trip from Germany, and wanted to go to sleep soon and didn’t really care where that would be. That was true of most medical evacuation patients. I didn’t find any reason we’d typically hospitalize a patient, such as suicidal thoughts, psychosis, or inability to care for self. I told him my opinion, but that I had to run it by my boss and then find the nurse to let her know.
As a resident, I had to get the approval of the on-call attending psychiatrist to not hospitalize a patient. Staying at home overnight, he agreed with me that this soldier could leave the hospital, but warned me the casualty receiving nurse might push back because Sam required a wheelchair.
Since I had been a general medical officer for five years before returning to residency, the nurse, my attending boss, and I all had the same rank. They were Army majors, and I was a Navy lieutenant commander. When I found the nurse, she was friendly, but seemed disappointed that we shared the same rank. She couldn’t push me around as I imagined she did with most residents. She tried a more collegial approach with me. I still remember the conversation, almost twenty years later.
“Look, I get it. He doesn’t meet your usual criteria, but he’s not safe for our housing,” she said. “He’s in a wheelchair.”
“I don’t understand. Don’t you normally take soldiers into base housing with physical injuries who can’t walk?”
“The few rooms set up for wheelchairs are all full. What happens if he falls and he can’t get back in his chair? They’ll be no one there to help him.”
To be honest, her argument seemed so compassionate on the surface, but so twisted in its logic, that it dumbfounded me a bit. I’d been a physician in remote areas, unpracticed in arguing about a large system’s limited resources. You’d think a place so big always had more rooms. I suspected she just didn’t want to bother with him.
“You have no more handicap accessible rooms?”
“Housing is really tight. I think it’s best he goes on your ward.”
The hospital and its outpatient housing were both close to capacity, or even overflowing. But on an interpersonal level, doctors and nurses don’t like the other telling them what to do or obstructing their plans. It’s always been that way. Both assume negative motivations in the other: nurses are lazy and doctors don’t have to consider the non-medical details of caring for a patient.
“Is this because he’s a psychiatric patient?”
“We can’t take care of him in an outpatient housing. I’m happy to talk to your attending and go up my chain of command about this.”
She pulled the going-to-the-authorities card. Whether or not she was right, I didn’t want her to talk to my attending. That meant I couldn’t handle my responsibilities, and she was cutting me out of the discussion.
She saw my uncertainty and moved in like a shark smelling blood. “Look, he likely won’t mind going on the ward. Go present it to him as the safest way forward, until a better plan can be sorted out in the morning.”
Outmaneuvered, I went back to Sam. He agreed to spend the night on the ward. I called my attending back, and he reluctantly agreed, saying that he’d talk to the nurse’s boss in the morning. He either saw no other solution, or was allowing it to play out for my experience, perhaps because of similar battles he’d tried to fight within a system overwhelmed with causalities.
By then, my night had become pretty busy. I supervised the intern working on the ward as he assessed a patient. Then the emergency room paged me with another patient. I heard from a nurse as I was leaving the ward that Sam wasn’t cooperating with the admission process. He was yelling at the staff as they searched his belongings for anything dangerous and then put them in storage. I asked the nurse to help settle him down. Most patients don’t like their belongings being taken away, but I hadn’t warned him about it. Sometimes that helps.
About an hour later, a nurse called me. “You need to come back to the ward. We’re restraining the new patient. He wanted to smoke before he went to bed.”
“Why can’t he smoke outside?” There was a patio next to the ward where patients smoked under supervision.
“It’s already closed for the night.”
By the time I got to the ward, I found a horrible sight. The nurses had transferred Sam from the wheelchair to a restraint bed. They were belting his legs and arms to it, and he was fighting against them. When he saw me, he said, “Doc, get me out of here. I just wanted to smoke.”
Restraint rules required that I check the belts to make sure they weren’t too tight and that the patient didn’t appear injured from the process. As I did that, the nurses were also injecting a combination of sedative meditations into his butt cheek. He shouted, “Don’t give me that sh*t!”
A nurse said, “We’re having to give you this medication because you won’t calm down.”
At that point, the patient cursed but then whimpered and began to cry. I left the room.
I was required to call my attending if we restrained a patient on the ward.
“f*cking nurses. You should’ve just discharged him from the ward when he didn’t want to be there and made the medevac nurse do her job.”
“I was in the ER when they restrained him.” But I’d still been on the ward when he and the nurses were already clashing. My attending was right. I should’ve just discharged Sam before the restraint became necessary, since he clearly no longer wanted to be there and was what we call a soft or social admission, for lack of housing.
The nursed removed the restraints once the sedative medications kicked in and he fell asleep.
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The next morning, the ward’s teams of doctors held morning report. I had to present the events from last night to the ward’s attending psychiatrists, residents, interns, and medical students. There were always questions and critiques, but also teaching and constructive feedback.
The senior psychiatrist on the ward, an Army colonel, came down on me for admitting Sam. He pointed out, rightly, that the medevac nurse doesn’t understand that admission to a psychiatric ward isn’t like the other wards. We take away our patients’ freedom in order to help them. We should only do it as a last resort.
Perhaps defensive as I ended my presentation about Sam, I pointed out he had moved his legs voluntarily while fighting the restraint. The colonel scowled at me, said nothing, and walked out of the meeting. Sam’s new care team on the ward discharged him to outpatient housing on the hospital grounds later that day.
Looking back, I have to live with the fact that I gave up my authority as a physician and helped create the circ*mstances that led to Sam’s unnecessary restraint. I could’ve avoided it by telling the medical evacuation nurse that he didn’t need hospitalization and walking away from her. There were physical risks to him and the nurses who restrained him, along with risks of adverse reactions to the medications the nurses gave him as part of the restraint process. He likely left the ward wanting nothing to do with psychiatric care again and told his nightmare experience to others who also likely now hate psychiatry.
I learned from this experience the fear and anger that taking away control from another person can cause. I should’ve protected Sam from an unnecessary admission. All that’s true, but that leaves out that the medevac nurse might have been right also: there might not have been any viable housing options left if he’d remained an outpatient. She might’ve seen herself as standing up to us and preventing an unsafe situation.
It's easier, like the other doctors, to blame the nurses. One refused to take him into outpatient housing, and then others refused to let him smoke and then failed to de-escalate the situation. The nurses working on the psychiatric ward at the time were notorious for being rigid about rules and quick to restrain. A few nurses with more compassion might have prevented what happened after I admitted him. But I don’t entirely blame them. During my subsequent years as an attending psychiatrist in the military, I came to realize that there were much bigger issues than a few doctors butting heads with a few nurses and both sides refusing to listen to each other’s concerns. What happened to Sam was a symptom of systemic strain.
I think an overwhelmed system, ill-equipped for the number of casualties coming from Iraq in 2005, failed its staff and Sam and other soldiers. Housing for outpatients and support for them should have been more robust. In later years, the army stood up a medical brigade that received outpatients and provided robust support. The military built additional housing as well.
In 2005, there simply weren’t enough resources. The insurgency in Iraq raged. American casualties mounted. Nurses and doctors didn’t have the support they needed.
And of course, Sam could’ve simply gone to bed without smoking. Looking back, I’d become angry at him for not doing that, and not being an easy, ambulatory patient who could’ve gone to a regular room. Why did he have to have such a powerful reaction to risking his life in an unpopular war? Without knowing it, I sacrificed my compassion for his lack of conformity in order for myself to conform.
I never saw Sam again. He might’ve had a classical conversion disorder. He might’ve turned out to have a medical cause that kept him from walking. Moving his legs during the restraint process didn’t prove he was faking or unconsciously overwhelmed. If anything, my satisfaction that Sam moved his legs proved something about me. I was capable of participating in punishing someone who didn’t go along, whether that meant he should’ve stayed and fought in Iraq or should’ve gone to bed on the ward without a cigarette. That truth about myself took me a long time to accept.
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Perhaps Sam was saner than I was back then, saner than all of us who adapted ourselves to those circ*mstances. Every morning after my night shift there at Walter Reed that month, I returned home to my wife and young son as if I’d just come back from a night of trick-or-treating. I took off my scrubs like they were a mask and lived a normal life with them. I acted as if I hadn’t just left a hospital overflowing with the casualties from a war no one wanted to talk about. Like all the other Walter Reed staff, I tried not to think about or connect those two worlds. If had, maybe I wouldn’t have been able to walk either.
